WFI Components CHAPTER 2.docx - Firefighter Cancer Support

							                WFI CHAPTER 2 — Medical Evaluation

 Management and Labor shall support the provision of the comprehensive
      annual medical exams as a component of the WFI Program.

This chapter highlights the following:
     Introduction
     Physical Examination
     Body Composition
     Annual Laboratory Analyses
     Vision Evaluation
     Hearing Evaluation
     Pulmonary Evaluation
     Aerobic/Cardiovascular Evaluation
     Cancer Screening
     Immunizations
     Infectious Disease Screening
     Referrals to Health Care Practitioners
     Written Feedback
     Data Collection and Reporting

INTRODUCTION

The WFI is a progressive model for delivering a preventive and occupational health care services
program for today’s fire fighters and emergency medical workers (collectively referred to as
“uniformed personnel”). The purpose of the WFI is to ensure that uniformed personnel are healthy
enough to work safely and effectively during their careers and maintain good health during their
retirement. The need for this type of program is based on the unique risks and adverse working
environments that uniformed personnel face daily. The intent of the program is that it is
implemented as a mandatory, non-punitive program where all uniformed personnel work to
improve his or her health or wellness, competing only with themselves. Due to the physical
demands of the job, it is essential that all uniformed personnel maintain a high level of fitness and
wellness. In addition, these individual’s face unique psychosocial stressors that are a result of the
constant exposure to tragic events and suffering. Therefore, the creation of a comprehensive health
and wellness program is essential to provide the medical and psychological support needed for
uniformed personnel. Properly implemented, the clinical program outlined in this chapter will
allow for an appropriate medical assessment, early detection of diseases and illnesses, as well as
implementation of health promotional programs. The annual medical examination is an integral
element that provides invaluable health status assessments of both the individual and department
wide. Moreover, collecting unidentifiable aggregated data during such exams allows for long-term
analysis and the implementation of preventive programs.
Medical Evaluation and Assessment
The medical evaluation outlined in this chapter is intended to accomplish the following to identify
whether an individual is physically and mentally able to perform essential job duties without undue
risk of harm to self or others; monitor the acute and long-term effects of the working environment
of uniformed personnel, including exposure to chemical and biological agents, and the effects of
physical and psychosocial stressors in the workplace; detect patterns of disease in the workforce
that might indicate underlying work-related health concerns; provide quantifiable medical
information on the entire workplace; inform uniformed personnel of their occupational hazards
and health status; provide a cost-effective investment in health promotion and disease prevention
in the fire service; and to comply with federal, state, provincial and local health and safety
requirements. A comprehensive medical assessment shall be conducted annually and standardized
to include all of the components of this chapter. Individuals may use any designated fire
department physician, or other providers, to conduct the medical assessment. Uniformed personnel
may elect to have certain components of the medical evaluation (i.e. invasive genitourinary
examinations) completed by their primary care physician. If this option is chosen, exams given by
primary care physicians must be done within the prescribed schedule and the results reviewed by
the fire department medical provider and recorded in the member’s confidential fire department
medical record. All medical assessment results, regardless of where they were obtained or
performed, shall remain confidential. Recently, there have been some varying recommendations on
the intervals of medical assessments usually based on an individual’s age. However, the value of
providing annual medical assessments for uniformed personnel within a high-risk occupation has
been determined by the WFI Task Force to be medically significant. It is a cost-effective program,
based on a history of saving members’ lives through early intervention. The National Fire
Protection Association within its health, safety, medical and fitness standards for fire departments
has also recognized and specifically requires annual medical assessments.

Medical History Questionnaire
An initial pre-employment history questionnaire for establishing a medical baseline and a periodic
medical history to provide follow-up information and to identify changes in health status must be
completed during each medical assessment.

Physician Responsibilities
All examining physicians are designated by the department to evaluate patients for the WFI. This
continuum of care involves: candidate medical evaluations; annual medical/ fitness evaluations;
injury/illness care and rehabilitation; pre-retirement medical evaluations (post-retirement exams
where provided); and return to work evaluations. The physician must have a thorough
understanding of the positions in the fire department, including: essential job tasks; physical
demands; psychosocial stressors; chemical, biological, and physical exposures; and the effects of
medical conditions on essential job tasks. It is important that the physician understand and
participate as a member of a multidisciplinary WFI Team. The physician is a vital
advisor/consultant to both labor and management on all medical issues.
Physicians must maintain complete adherence to medical confidentiality. Specific information
regarding the medical examination, evaluation, laboratory results and medical diagnosis shall not
be released unless written permission is obtained from the individual. Employees need to feel
assured that the information provided to the physician will not be shared unless consent is granted.
Finally, the fire department physician must have knowledge of local, state, provincial, and federal
laws related to health and safety.
PHYSICAL EXAMINATION
Vital Signs
A physical examination begins with the assessment of height, weight, blood pressure, temperature,
heart rate, and respiratory rate. Blood pressure shall be a part of the baseline and annual
examination, with any necessary follow-up as medically indicated. Uniformed personnel with
known elevations of blood pressure must be educated about the long-term health effects of ignoring
this condition, which includes the possibility of stroke and coronary artery disease.
Head, Eyes, Ears, Nose, and Throat (HEENT)
This examination offers an opportunity for the examiner to assess each person’s ability to wear
head protection, a respirator face piece, and other respiratory protection. The examiner should
also review the importance of an uncompromised airway while wearing a respirator. Moreover, it
allows for identification of possible chronic exposures that may place the individual at risk for long-
term illnesses. The HEENT exam should emphasize early identification of treatable disease and
prevention strategies through education. It is also important to note that the examiner has an
opportunity to discuss the health hazards of tobacco such as: cancer; cardiovascular disease; lung
diseases; premature aging, and tobacco cessation strategies.
The HEENT exam includes a thorough evaluation of: head — evaluate the shape of a member’s face
looking for evidence of previous trauma or other gross abnormality that may interfere with the use
of SCBA or other Personal Protective Equipment (PPE); eyes — assess extra ocular movements,
pupillary light reflex and accommodation, conduct fundi/retinal exam, assess visual acuity,
peripheral vision, and color vision; ears — visualize the external ear canal and tympanic membrane,
inspect the external ear helix particularly for evidence of sun damage or cancerous lesions, and an
audiometric exam performed according to standard procedures is also required; nose — inspect for
patency of nares, septal cartilage deviation, evidence of polyps (usually secondary to chronic
inflammation), other mucosal changes (e.g., erythematous patches in smokers), and evidence of
tenderness over the paranasal sinuses throat — evaluate the oropharyngeal cavity, gums, teeth,
palate (hard and soft), tongue (dorsum and undersurface), tonsils and posterior pharyngeal wall,
also direct observation for pre-cancerous changes (e.g., color changes-leukoplakia, plaques,
nodules, and asymmetry) is important.
Neck
The exam should include evaluation of major vessels, lymph nodes, endocrine structures (salivary
and thyroid glands), physiologic functioning (e.g., swallowing, saliva production), assess for
abnormal masses, gland enlargement, or suspicious skin lesions. Range of motion of the cervical
spine should also be noted.
Cardiovascular (CV)
The CV exam must include: assessments of pulse (rate, regularity, and volume); seated blood
pressure (with the patient’s feet on the floor and the proper sized BP cuff); auscultation of the heart
(for heart sounds, extra sounds, clicks, and murmurs) and major arteries (carotid, abdominal aorta,
femoral for bruits); and if clinically indicated, examination for signs of decompensating heart
function (CHF) such as jugular venous pulse and peripheral (ankle) edema. In addition, a medical
assessment must include a thorough history and physical exam. It is imperative to inquire if there
are any recent changes in the patient’s aerobic capacity, which could indicate pulmonary or cardiac
disease. Typically, uniformed personnel suffering from early lung or heart disease will deny being
more fatigued while fighting fires. More common is the complaint that during the past year or two
the individual’s tolerance for exercise has diminished. The examiner must identify modifiable
cardiac risk factors such as: smoking; dyslipidemias (including: high total cholesterol/HDL-
cholesterol ratio, high LDL-C, high triglycerides, and low HDL-C); hypertension; diabetes; chronic
renal failure; metabolic syndrome (insulin resistance syndrome); sedentary lifestyle and/or
obesity; and nutritional concerns and/or deficiencies. Non-modifiable cardiac risk factors should
also be noted, such as: male gender; advanced age; and positive family history of premature
cardiovascular diseases or risks. For example, individuals with a family history of premature CAD
in a first-degree relative are at an increased risk of cardiovascular events.
Pulmonary
A pertinent history includes any complaints of exercise intolerance, cough, symptoms of
bronchospasm, and exposures (chemical or biological). The respiratory exam should include: an
inspection for respiratory rate and effort; presence of coughing or sneezing; skin color and any
clubbing of the digits (indicative of respiratory diseases); auscultation for breath sounds and any
abnormal sounds (expiratory wheezing, inspiratory crackles, or stridor); and if clinically indicated,
more specific exams for areas of consolidation or dullness (pneumonia, pleural effusions, etc.).
Spirometry is an effective screening and surveillance exam for pulmonary disease and shall be
included in the exam. Any changes in the spirometric indices, such as reductions in the vital
capacity and/or forced expiratory volumes should be subject to further evaluation by more formal
pulmonary function testing and/or evaluation by a pulmonologist.
Gastrointestinal
Gastrointestinal exam shall include inspection, palpation, percussion, and auscultation. Abdominal
obesity has been shown to be associated with increased inflammation in the body and concomitant
increased risk for several chronic diseases. Palpation for tenderness, organ enlargement, other
masses (tumors or hernias), and femoral lymph node enlargement is appropriate. Percussion and
palpation of major arteries for bruits and pulse volume (specifically abdominal aortic aneurysms, or
weak pulses indicative of arterial atherosclerosis) should also be performed. Generally, the right
upper quadrant is palpated for evidence of liver, colon or gall bladder disease; and the left upper
quadrant is palpated for spleen or colon pathology. Palpating the right and left lower quadrants is
helpful for evaluation of colon disease.
Genitourinary
• Men—this examination includes testicular, penis, and inguinal hernia evaluations, as well as
previously mentioned palpation of femoral pulses and for lymphadenopathy. This part of the
examination provides an opportunity for the examiner to discuss the merits of testicular and
prostate cancer screening, and techniques for self-examination of the testicles. This exam may be
deferred if the patient prefers to obtain these exams from his own primary care physician.
• Women - this examination includes vaginal and bimanual pelvic exams, the Pap smear, breast
exam, and mammography. This part of the examination provides an opportunity for the examiner
to discuss the merits of breast and cervical cancer screening and techniques for self-examination of
the breasts. This exam may be deferred if the patient prefers to obtain these exams from her own
primary care physician or women’s health care facility.
Rectal
The purpose of this procedure is to screen for rectal masses, mucosal abnormalities such as
hemorrhoids, anal fissures, and cancerous lesions, and to detect prostate abnormalities in men. All
uniformed personnel shall receive annual digital rectal exams (DRE) for detection of lower
intestinal masses, prostate gland enlargement (men), atypical prostate tenderness, or surface
irregularities and nodules.
Lymph Nodes
An examination of the lymph nodes for enlargement, tenderness, and mobility in the cervical,
supraclavicular, inguinal, and the axillary regions is to be conducted.




Neurological
The neurological examination for uniformed personnel shall include a general assessment of mental
status, cranial nerve function, motor system, sensory system, cerebellar function/coordination,
balance and gait, and reflexes.
• Mental Status Exam— a general mental status exam focuses on orientation, memory (short and
long term), and judgment. If clinically indicated refer for psychiatric and/or psychological
evaluation for addition assessment.
• Cranial Nerves Exam—a focused cranial nerve examination includes an emphasis on the senses.
The cranial nerve exam includes: CN1-smell (often omitted unless history of head trauma or toxic
inhalation); CN2-vision; CN3-pupillary constriction; elevation of the eyelid; extra ocular eye
movements; CN4-extraocular eye movement; CN5-jaw movement; CN6-extraocular eye
movements; CN7-muscles of the face; CN8-hearing and balance; CN9-taste; pharynx movements;
CN10- movement and sensation in the oropharynx; CN11-movement of the neck muscles; and
CN12-tongue movement. A more thorough evaluation may be necessary if clinically indicated (e.g.,
headaches, dizziness/vertigo, or syncope).
• Peripheral Nerve Exam—peripheral nerve function is assessed in the motor and sensory portions
of the neurological exam. Decreases and imbalances in muscular power can predispose uniformed
personnel to musculoskeletal injuries. Thus, a general (motor assessment as measured by a 0 to 5
subjective rating of power) is important as it pertains to safe and injury-free work performance.
The peripheral neurological examination is usually continuous with the cranial nerve evaluation.
However, such peripheral motor, sensory, and reflex examinations may be conducted in
conjunction with the musculoskeletal exam.
Motor — gait, heel-to-toe, and Rhomberg (feet together, arms outstretched, palms up and eyes
closed) screening examinations for cerebellar function must be conducted. Muscle strength is
tested in all major muscle groups. Because of the physical demands on fire fighters, any evidence of
decreased muscle strength (as measured on the standard 0-5 scale) raises significant concerns
regarding work performance and must be addressed.
Sensory — the examination includes pain, thermal sensation, light touch, position, two point
discrimination, and vibratory sensation testing. Thermal evaluations are generally omitted if the
pain examination is normal.
Reflexes — this examination includes the standard evaluation of reflexes on a 0-4+ scale, including
the ankle, knee, bicep, tricep, and brachioradialis.
Musculoskeletal
In addition to the motor assessment, the examiner inspects and palpates for: structural
asymmetries (e.g. areas of muscular imbalance and atrophy); active range of motion of all major
joints (including the back); the sensation of pain with any of the above; and a complete joint specific
examination where clinically indicated. Any musculoskeletal limitations or areas of pain are
important to note, not only for the timely provision of physical therapy, but to record those injuries
that may be relevant to future workers’ compensation, pension, or disability claims.
Skin
The examiner shall inspect the skin for color, vascularity, lesions, and edema. Careful examination
of the skin for abnormal/atypical nevi (moles) or other suspicious lesions that could be cancerous
(non-melanoma or melanoma types) is critical. The clinician should have a low threshold for
referring a patient to a dermatologist when suspicious or atypical changes are present. Also note
any rashes, scars, tattoos, or obvious evidence of trauma/injury (bruising, excoriations, scraps, cuts,
swelling, erythema, warmth, or tenderness).
BODY COMPOSITION
Body composition differentiates between the relative amounts of adipose tissue (fat) and lean body
mass. Lean body mass consists of muscle, bone, organs, nervous tissue, and skin. Body fat is
traditionally thought of as a passive tissue that serves to insulate and protect the body and its
organs, and as a reservoir for energy storage. Although some body fat is considered essential,
excess body fat increases the workload and amplifies heat stress by preventing the efficient
dissipation of heat when a person exercises. In addition, added body fat elevates the energy cost of
weight-dependent tasks such as climbing ladders and walking up stairs, also contributing to
injuries and an increased risk of many chronic diseases. Obesity is overtaking smoking as the
number one cause of preventable deaths and is associated with an increase in almost every chronic
disease including but not limited to: cardiovascular disease, hypertension, dyslipidemia, heart
failure, diabetes, several types of cancer, asthma and chronic lung diseases, obstructive sleep apnea,
dementia, arthritis, and gastro esophageal reflux disease.
Evaluation of Body Composition
Methods for evaluating body composition include: circumferential measurements, hydrostatic
weighing, Bod Pod, bioelectrical impedance analysis (BIA), skinfold measurement, and body mass
index (BMI). The accuracy, reliability and practicality of these methods vary. There is ongoing
research on the most accurate and consistent method for evaluating body composition. However,
the WFI has selected the skinfold measurement evaluation as the preferred method of estimating
body composition.
Distribution of Body Fat
Recent scientific research suggests that the distribution of body fat is an important predictor of
negative health outcomes. Individuals with more intra-abdominal/visceral fat, which is fat around
abdominal organs, are at an increased risk of hypertension, type-2 diabetes, dyslipidemia, coronary
artery disease, and premature death. This visceral adipose tissue is metabolically different than
subcutaneous fat. Excessive abdominal fat, as revealed by waist circumference measures, creates
increased inflammation in the body. This occurs because fat cells release pro-inflammatory
cytokines, cell-signaling molecules that activate the immune system, which ‘turns on’ an
inflammatory cascade at genetic and cellular levels, ultimately affecting the entire body. This is
important because current scientific research links chronically increased inflammation to several
chronic disease states such as cardiovascular disease, prediabetes/diabetes, cancer, and dementia,
and others. Thus, abdominal fat is no longer thought of as just a passive or inert reservoir for
storing energy; it is an active endocrine organ, secreting many factors capable of increasing
systemic inflammation within the body. Expert consensus indicates that a waist circumference
measurement, measured at the level of the iliac crests, that is greater than 102cm (40 inches) in
men, and 88cm (35 inches) in women imparts a significant increase in the risk of chronic disease,
including cardiovascular disease. Obesity, and in particular abdominal obesity, is a health risk that
must be managed aggressively.
ANNUAL LABORATORY ANALYSES
Prior to reporting to a physician for an annual medical examination, uniformed personnel may have
their blood drawn and urine sampled and analyzed at a designated laboratory site. Having the lab
results available at the time of the physical exam will assist physicians in providing a more
thorough examination and allowing physicians to address any concerns based on the laboratory
results. If blood is drawn and urine sampled during the annual examination, results are provided to
physicians for a follow up and/or addressed in the Health Risk Appraisal.
Blood Analysis
The following are components of the blood analysis. At a minimum, laboratory services must
provide these components in their automated chemistry panel (CMP) and complete blood count
(CBC) protocols. If laboratory tests are not done prior to the scheduled physical examination,
laboratory tests will be drawn at the time of the medical examination. Blood drawn for medical
analysis will not be used for drug screening at any time. The minimum blood analysis to be conducted
as a part of the annual medical examination, includes: white blood cell count (with differential);
platelet count; red blood cell count (hemoglobin and hematocrit; liver enzymes (AST, ALT, LDH)
and function (alkaline phosphatase, bilirubin, albumin) tests; glucose — fasting; creatinine and
glomerular filtration rate (GFR); blood urea nitrogen; sodium; potassium; carbon dioxide; total
protein; calcium; lipids (cholesterol and triglycerides) fasting.
• White Blood Cell Count
White blood cells (WBC) are an important part of the body’s immunologic system. The role of white
blood cells is to help the body defend itself against infection. An elevated WBC count may suggest
an acute bacterial or viral infection, various leukemia’s, acute blood loss, renal failure, pregnancy, or
an inflammatory disorder (such as inflammatory bowel disease), or it may indicate the effects of
acute severe emotional/physiological (e.g., burns, trauma) stress on an individual. Situations
where the WBC count is low can include: chronic viral or bacterial infection, acute leukemia’s,
immunosuppressive disorders (e.g., HIV), autoimmune diseases (e.g., lupus), chemical and heavy
metal toxicities, drug effects (e.g., some antibiotics and analgesic medications), and perhaps chronic
emotional stress (which could be construed as ‘normal’ depending on the circumstances of the
individual). The WBC differential helps to determine the significance of an abnormal WBC count.
• Differential
The WBC differential identifies relative amounts of different types of white blood cells and helps to
identify different clinical problems. For instance, a high neutrophil count might indicate: an acute
bacterial infection; presence of immature neutrophils (bands) could mean acute leukemia; excess
eosinophils may indicate a parasitic infection or allergic reaction; or an increase in lymphocytes
may indicate a chronic inflammatory condition, infection or chronic type of leukemia.
• Red Blood Cell Count
The purpose of red blood cells is to carry oxygen to the body’s tissues. The routine measures of the
blood’s oxygen carrying capacity are hemoglobin and hematocrit. An increase in the number of
RBC’s may indicate dehydration, a myeloproliferative disorder called polycythemia, or conditions of
hypoxia such as emphysema and smoking. Decreased levels may indicate anemia, acute blood loss,
or hemodilution.
• Platelet Count
Platelets are essential to the bloods ability to properly clot. Abnormally low platelet counts, known
as thrombocytopenia, may be caused by a decrease in production possibly stemming from bone
marrow suppression, clumping or destruction of platelets from sequestration in the tiny capillaries
of the spleen. High platelet counts are associated with myeloproliferative disorders such as
polycythemia, essential thrombocytosis, or chronic myelogenous leukemia.
• Liver Enzymes and Function Tests
The following liver assessment tests are used primarily to detect and monitor liver disease. These
tests measure either liver injury (enzymes, also referred to as liver transaminases) or liver function.
An increasingly common cause of elevated liver enzymes is fatty infiltration of the liver, due to
obesity, referred to as ‘non-alcoholic fatty liver disease.’ Abnormal results are caused by many
other medical conditions or medical treatments.
Aspartate aminotransferase (AST)—is distributed through many tissue types with high
concentrations in liver, heart, skeletal muscle, and kidney. It is elevated in liver conditions of
infection (hepatitis), obstruction (e.g., gall bladder stones), cirrhosis, fatty infiltration, myocardial
stress (acute MI, infection, heart failure), skeletal muscle trauma or vigorous exercise, medication
use (e.g., acetaminophen or isoniazid), or alcoholism. Low levels are due to vitamin B6 deficiency,
renal failure, or protein deficiency/malabsorption.
Alanine aminotransferase (ALT)—is typically elevated in liver disease, although there are small
amounts of this enzyme in heart, kidney, and muscle tissues. It is more liver specific than is AST.
Typically alcoholism, hepatitis, obstructive jaundice, liver cancers, cirrhosis, acute MI, trauma to
skeletal muscle, and salicylate (ASA) toxicity can cause ALT elevation.
Lactate dehydrogenase (LDH)—is an enzyme present in all cell types and is released when they are
damaged. It is elevated in liver disease, malignancy, hemolytic anemia (rupture of red blood cells),
pulmonary infarct, muscular or myocardial injury, or trauma.
Alkaline phosphatase (Alk Phos)—is present in high concentrations in growing bone and in bile. It is
elevated in diseases involving the liver, especially any disease process that impairs bile formation
or flow (e.g., zepatic duct blockage with stones, metastatic carcinoma of liver), thus it is a liver
‘function’ test. Diseases of the bone (e.g., bone metastases, Paget’s disease, osteomalacia, rickets,
hyperparathyroidism, healing fracture, or myositis ossificans) also increase this enzyme.
Decreased levels might indicate hypothyroidism, very low fat/low protein diets, zinc deficiency,
excessive vitamin D intake, or blood type A.
Bilirubin— is formed when RBC’s break down and release their bilirubin (heme metabolism), which
is then conjugated in the liver for excretion in the bile. High levels of bilirubin in the blood may be
due to abnormalities of formation, transport, metabolism, and excretion. This makes bilirubin a
liver ‘function’ test. Jaundice results from high bilirubin concentrations in the serum. Elevated
bilirubin levels are classified as unconjugated or conjugated hyperbilirubinemias. Unconjugated
(indirect) hyperbilirubinemias are caused by: increased bilirubin production (e.g., hemolytic
anemias or reactions); impaired bilirubin uptake by the liver (due to certain drugs); or impaired
conjugation (Gilbert’s disease is a common cause of elevated bilirubin which is caused by a
decreased level of a conjugation enzyme). Conjugated (direct) hyperbilirubinemias result from:
impaired excretion of bilirubin from the liver due to hepatocellular disease (hepatitis, cirrhosis);
intrahepatic cholestasis (blockages within the liver) from drugs, sepsis, and hereditary
cholestatic syndromes; or extrahepatic biliary obstruction.
Albumin —is a protein made by the liver, thus it is a liver ‘function’ test. Decreased levels of
albumin can be the result of: liver disease or dysfunction (e.g., hepatitis, cirrhosis, necrosis, fatty
liver); malnutrition; malabsorption; alcoholism; some chemical and heavy metal toxicities; systemic
infections; chronic inflammation; insulin resistance; obesity; autoimmune diseases; renal diseases
(nephrotic syndrome, glomerulonephritis); congestive heart failure; over hydration; leukemia; or
pregnancy. Albumin may be high with dehydration, shock, and prolonged tourniquet use during
venipuncture, and with steroid therapy.
• Glucose
Glucose in adequate levels is essential for all normal body functions. Cells use glucose as a fuel
substrate for the production of adenosine triphosphate (ATP), the basic source of energy used in all
metabolic reactions — both anabolic (synthetic reactions that convert simple molecules into larger
more complex molecules) and catabolic (reactions that breakdown or degrade larger molecules
into simpler ones). Insulin is a hormone that regulates glucose metabolism. Diabetes results from a
lack of insulin, a lack of sensitivity to insulin or both. Blood glucose may be tested in a multistep
process to determine if one has diabetes or is at risk of developing diabetes. Fasting blood glucose
levels are easier to interpret than are random levels although both measurements may be useful in
the diagnosis of diabetes.
• Creatinine (Cr)
This is a measure of renal function. It is a product of muscle metabolism that is produced in the
blood stream at a relatively constant rate and cleared by renal excretion. The kidney filters blood
through millions of sieves, glomeruli, which retain essential components of the blood in the body
followed by selectively reabsorbing anything that was missed by the glomeruli in the renal tubules.
Creatinine is freely filtered by the kidney and not reabsorbed by the renal tubules. It is not a
perfect indicator of renal function as other factors can alter serum creatinine measurement.
Conditions causing elevation of creatinine include: the use of drugs, such as aspirin, cimetidine,
trimethoprim, cephalothin, and cefoxitin; ketoacidosis; and increased protein intake or muscle
mass. Conditions causing decrease of creatinine include: advanced age due to physiological
decrease in muscle mass; cachexia, due to pathological decrease in muscle mass caused by cancer
and malnutrition; and liver disease, due to a decrease in hepatic creatinine synthesis and cachexia.
• Glomerular Filtration Rate (GFR)
This is the best index of overall kidney function and is a more sensitive, and early, indicator of
kidney dysfunction than creatinine alone. Creatinine clearance, done with 24 hours of urine
collection, is the usual means of estimating GFR. Urine collection for a full 24 hours is impractical
for patients and prone to error. Many laboratories now estimate GFR using the modified MDRD
GFR equation which uses the patient’s age, gender, race, and measured serum creatinine level. This
estimate of GFR is often included with the serum creatinine on the laboratory results chart.
• Blood Urea Nitrogen (BUN)
Urea is another useful index of renal function. It is synthesized mainly in the liver and is the end
product of protein catabolism. The kidney excretes this nitrogenous waste product of protein
catabolism. Kidney damage reduces its excretion and is a marker of renal failure and disease.
Urea is freely filtered by the kidney with approximately 30-70 percent being reabsorbed in the
renal tubules, but is dependent upon the hydration status of the individual. The reabsorption of
urea may be decreased in well-hydrated individuals, causing a low BUN level; whereas dehydration
causes increased reabsorption causing a higher BUN level, as is often seen after a prolonged fast
with little water intake. A normal BUN: creatinine ratio is 10:1; with dehydration the ratio can
increase to 20:1 or higher. There are conditions other than renal disease that affect BUN,
independently of GFR. Circumstances which could increase BUN include: conditions that reduce the
effective circulating blood volume (e.g. dehydration, congestive heart failure, or acute blood
loss/shock); catabolic states (e.g. gastrointestinal bleeding or corticosteroid use); high protein
diets; and drugs such as tetracycline, analgesics, or Naiads. Circumstances which could decrease
BUN include: liver disease; malnutrition, low protein diet and cachexia; and over hydration.
• Sodium
Sodium is an important electrolyte in the body. Abnormal serum sodium does not necessarily mean
a problem with the sodium ion balance, but is most often due to abnormal water balance, generally
associated with abnormal serum osmolality and shifts of water across the cell membrane. The most
common and complicated disturbance of sodium is hyponatremia, low sodium concentration.
Generally it results from water imbalance, not sodium imbalance; and its differential diagnosis
starts with measurement of the patient’s serum osmolality as low, normal, or high, then
determination of their extracellular fluid volume as low, normal, or high. The most common
reasons for hyponatremia can include situations where the patient’s serum osmolality is low and
their volume status is low or normal. If their volume status is low, hypovolemia, it may be the
result of: dehydration; vomiting; or diarrhea which causes extra renal salt losses; certain
medications such as diuretics and ACE inhibitors, or in aldosterone deficiencies. If volume status is
normal, hyponatremia is usually due to the syndrome of inappropriate antidiuretic hormone
secretion (SIADH). Patients who are hyper volemic, in edematous states, with hyponatremia have
congestive heart failure, liver disease, nephritic/nephrotic syndrome, or advanced renal failure.
Hypernatremia, high sodium concentration, occurs most commonly when free water intake has
been inadequate. This is not an exhaustive list of causes for hypo/hypernatremia and specialist
consultation may be appropriate.
• Potassium
Potassium is another important electrolyte in the body, with 95 percent of potassium residing
inside cells. The plasma potassium concentration is maintained in a narrow range through two
main regulating mechanisms: potassium shift between intracellular and extracellular
compartments; and modulation of renal potassium excretion. Potassium levels may be elevated,
known as hyperkalemia, in patients taking certain medications that inhibit potassium excretion:
ACE inhibitors, angiotensin receptor blockers, potassium sparring diuretics, or their combination.
Other medications that can cause hyperkalemia include: NSAIDs, trimethoprim, tacrolimus, and
heparin. Otherwise the causes of hyperkalemia involve clinical situations where there is: decreased
excretion of potassium, shift of potassium out of cell, spurious causes or if there is excessive intake
of potassium. Low potassium levels, called hypokalemia, in situations where there is decreased
potassium intake, potassium shift into the cell (alkalosis, excess insulin, or trauma), renal
potassium loss (aldosterone deficiency, therapy with diuretics such as furosemide and thiazides,
hypomagnesemia, renal tubular acidosis), or if there is extrarenal potassiumloss (vomiting,
diarrhea, or laxative abuse). This is not an exhaustive list of causes for hyper/hypokalemia and
specialist consultation may be necessary.
• Carbon Dioxide (Bicarbonate)
Carbon dioxide levels are an indicator of the acid-base status of the patient. The measurement of
venous carbon dioxide is actually a direct determination of the bicarbonate anion concentration.
Therefore, for clinical purposes the total carbon dioxide content is equivalent to the bicarbonate
anion concentration. Disturbances in acid-base balance can be caused by a variety of primary
metabolic and respiratory disorders (more acute situations), or they can be due to a combination of
the two (in more chronic situations where there has been compensation for the primary disorder).
Primary respiratory disorders affect blood acidity by causing changes in the arterial partial
pressure of carbon dioxide, and primary metabolic disorders are indicated by changes in the
bicarbonate anion concentration. The medical workup of the patient with an acid-base disorder is
complicated and may require specialist consultation.
• Total Protein
Total protein is a measure of the total proteins in the serum (albumin and globulins). Plasma also
contains fibrinogen protein so if the lab result is high, ensure that the serum was measured and not
the plasma. Total protein levels can be elevated in chronic infection, chronic liver disease,
alcoholism, dehydration, multiple myeloma, lymphoma, and some autoimmune diseases. Levels are
low in malabsorption, malnutrition, severe liver disease, chronic renal failure, nephrotic syndrome,
over hydration, and protein losing states.
• Calcium
Calcium is measured in the serum or plasma and is required for normal muscle contraction and
nerve function. It is the ionized calcium in blood that is usually measured, and any variation from
the normal range is usually highly significant. Calcium is usually elevated, known as hypercalcemia,
due to primary hyperparathyroidism or a malignancy (e.g., multiple myeloma, lymphoma, or
tumors that secrete PTH). These two reasons account for 90 percent of all cases of high calcium.
Other causes of hypercalcemia are: increased intake or absorption of antacids or excess vitamin D
or A; other endocrine diseases such as adrenal insufficiency, or pheochromocytoma; sarcoidosis;
Paget’s disease of the bone; drugs such as thiazide diuretics or lithium; and conditions leading to
immobilization. Ionized calcium may be low, hypocalcemia, in conditions where there is
insufficient action of PTH (e.g., hypoparathyroism) or active vitamin D. The most common cause for
low total calcium is low albumin states (where correction, by the lab or with a formula, of the serum
calcium concentration is needed to accurately reflect the ionized calcium concentration). The most
common cause of hypocalcemia is renal failure due to decreased production of vitamin D. Other
important causes include: decreased intake from malabsorption or vitamin D deficit; increased loss
resulting from diuretics or alcoholism; hyperphosphatemia; and sepsis. The medical workup of the
patient with hyper/hypo-calcemia can be complicated and may require specialist consultation.
• Lipid Tests
A full lipid panel is a critical component of the laboratory testing profile for the WFI. In the general
population, a positive correlation between plasma cholesterol and coronary risk has been well
documented. Fire fighters are at an even higher risk of cardiovascular events in the course of their
duty, especially during fire suppression. Among fire fighters, almost half of line-of-duty deaths can
be attributed to cardiovascular events. Hypercholesterolemia is one of the major modifiable risk
factors in efforts to prevent coronary artery disease and cardiovascular events.
Total Cholesterol—cholesterol belongs to a larger family of biological chemicals called lipids (fats).
Because it is such a critically important substance, a complex carrier system has developed to move
cholesterol through the entire body. This system consists of a number of proteins that bind to
cholesterol and transport it to where it is needed. Cholesterol, a lipid, when bound together with
one of these carrier proteins, is called a lipoprotein. Both total cholesterol and carrier proteins can
be measured in blood samples. When looking at total serum cholesterol levels, the risk of
developing atherosclerotic coronary vascular disease increases as the total cholesterol level
increases.
Low Density Lipoprotein (LDL-C) level —LDL-C is 45 percent cholesterol by weight and is the major
carrier of cholesterol to the body’s tissues. Since LDL can deliver too much cholesterol to the wrong
places (like the heart arteries) resulting in cholesterol plaque build-up, people often refer to this as
a bad cholesterol.
High Density Lipoprotein (HDL-C) level — HDLC is 30 percent cholesterol by weight and is involved
in reverse transport of cholesterol away from body tissues and out of the body. HDL cholesterol
removes excess cholesterol from the arteries, helping to prevent the build-up of cholesterol
plaques. Because this lipoprotein appears to remove excess cholesterol, it is often referred to as the
good cholesterol.
Total Cholesterol/HDL Ratio — TC/HDL-C ratio gauges relative risk of cardiovascular disease. The
importance of the protective effect of HDL cholesterol is emphasized by this ratio. The total
cholesterol level may be within a normal range but combined with low HDL cholesterol level, the
ratio indicates the individual is at a higher risk than someone with normal total cholesterol and a
normal HDL level. While cholesterol tests are part of the annual examination, the WFI strongly
recommends that a fasting lipid profile be conducted at least once every five years. Further, a non
fasting total cholesterol > 200 or HDL cholesterol < 40 indicates the need for a fasting lipid profile.
Risk factors for cardiovascular disease that need to be considered in the interpretation of results
and in further determining additional fasting lipid profile testing include age > 45 years for males
and > 55 years for women, current cigarette smoking, hypertension, HDL cholesterol below 40 and
a family history of premature coronary heart disease defined by a definite myocardial infarction or
sudden death before age 55 years in a male first-degree relative and before age 65 in a female first-
degree relative. A desirable LDL level in individuals without identifiable coronary heart disease is <
160 mg/dl with zero risk factors and < 130 mg/dl for two or more risk factors. The desirable LDL
cholesterol level for those individuals with known coronary artery disease or risk equivalents
including symptomatic carotid artery disease, peripheral arterial disease, abdominal aortic
aneurysm, and diabetes mellitus is < 70 mg/dl. Given the increased physiological demand imposed
by the fire service, cholesterol-lowering therapy including lifestyle modification and medication
when necessary is recommended for the achievement and maintenance of desired cholesterol
levels.
Metabolic Syndrome
Metabolic syndrome also referred to as syndrome X, insulin resistance syndrome, and pre-diabetes, is
characterized by dysfunctional metabolic factors probably linked by a common underlying
mechanism. From a clinical standpoint, diagnosing the metabolic syndrome identifies individuals
who are at increased risk for cardiovascular disease, including coronary heart disease, stroke, and
peripheral artery diseases and/or type-2 diabetes. Metabolic syndrome is characterized by a
clustering of risk factors for cardiovascular disease that include: insulin resistance (reduced cellular
insulin action); abdominal obesity; atherogenic dyslipidemia (changes to lipids that promote
atherosclerosis which include a combination of elevated triglyceride levels and atherogenic low-
density lipoprotein (LDL) cholesterol particles; and low levels high-density lipoprotein (HDL)
cholesterol); hypertension; hyperuricemia (high serum uric acid); a prothrombotic state (enhanced
blood clotting); and a proinflammatory state (increased systemic inflammation). While many
factors such as insulin resistance, abdominal obesity, physical inactivity, hormonal imbalances, and
a poor diet are likely the prime factors in the development of metabolic syndrome, genetic factors
(especially family history of type 2 diabetes) also play a role in its pathogenesis. Individuals with
metabolic syndrome are at increased risk for the development of coronary heart disease and other
diseases related to plaque buildup in artery walls, such as stroke and peripheral vascular disease, as
well as type-2 diabetes mellitus. Prospective population studies show that compared to individuals
without metabolic syndrome, those who have it are at least double the relative risk for
cardiovascular disease events, and a 5-fold increase in the risk of developing type 2 diabetes.
Therefore, it is important to identify those with metabolic syndrome and refer for treatment. The
metabolic syndrome is identified by the presence of three or more of the following components:
abdominal obesity defined as a waist circumference >102 cm (>40 in) in men or >88cm (>35 in) in
women; triglycerides 150 mg/dL; HDL cholesterol <40 mg/dL for men or <50 mg/dL for women;
blood pressure 130/85 mmHg; and fasting glucose 110 mg/dL.
Heavy Metal and Special Exposure Screening
Baseline testing for heavy metals and special exposures may be performed under special
circumstances, such as hazardous materials exposures; recurrent exposures; other known
exposures; or where under federal, state, or provincial regulations requires it, such as OSHA
standards. The following screenings may be utilized: urine screen assesses exposure to arsenic,
mercury and lead; blood screen for lead and zinc protoporphyrin assesses exposure to lead; testing
and screening for specific exposure or other heavy metal screens may include aluminum, antimony,
bismuth, cadmium, chromium, copper, nickel and zinc; and special blood testing may be ordered for
organophosphates, RBC cholinesterase, or other toxic exposures such as blood screening for
exposure to PCBs.
Urinalysis
Urinalysis will include both dipstick and/or laboratory microscopic evaluations.
The urine sample received for this analysis is not intended to be and will not be used for drug or alcohol
use screening at any time.
• Dip Stick Urinalysis pH —is the relative acidic or basic state of the urine can be an indication of
infection or chemical exposure. Glucose—excess glucose is seen in diabetes and renal tubule
disease.
Ketones—are abnormally elevated in uncontrolled diabetes, alcoholism, starvation, dehydration,
and with some weight reducing diets.
Protein—protein levels in urine can be elevated in kidney or urinary tract diseases including
cancers. The clinical significance of elevated protein on dipstick can be determined by performing a
24-hour urine test.
Blood — Dipsticks detect hemoglobin from analyzed red blood cell and myoglobin. Levels can be
elevated with hemolytic anemias, infections, kidney stones, tumors, dehydration, muscle
breakdown, and renal disease due to tuberculosis, trauma, glomerulonephritis, or cancer.
Bilirubin—dipsticks may be positive for bilirubin in liver disease, the breakdown of red blood cells,
and gallbladder obstruction.
• Microscopic Urinalysis -This includes evaluation for white blood cells (WBC), red blood cells (RBC),
WBC casts, RBC casts, and crystals. This testing helps to differentiate various kidney and urinary
tract diseases or trauma.

VISION EVALUATION
Assessment of vision must include evaluation of distance, near, peripheral, and color vision. Near
visual loss (presbyopia) is common in adults and increases in prevalence with increasing age
usually from the mid to late 40s on. Common visual disorders affecting adults include cataracts,
macular degeneration, glaucoma, and diabetic retinopathy. The visual evaluation must include:
visual acuity screening for both far vision acuity and near vision acuity; eyes must to be tested
separately; vision testing to determine both uncorrected and corrected visual acuity; color vision
testing must be assessed using color plates, such as Ishihara plates; when peripheral vision
evaluations are indicated, protocols specific to the test apparatus, not objects in the field, must be
utilized.

HEARING EVALUATION
By nature of their occupation, uniformed personnel are at an increased risk for noise-induced
hearing impairment at an earlier age. Baseline and annual audiograms are to be performed on all
uniformed personnel. To establish trends in hearing acuity, current audiogram must be compared
with all previous audiograms, including the baseline. Testing must be done in an ANSI-approved
soundproof booth. Pure tones are presented at various intensities until a threshold is established.
For the purposes of database collection, the following frequencies are tested: 500 Hz, 1000 Hz,
2000 Hz, 3000 Hz, 4000 Hz, 6000 Hz and 8000 Hz. In addition, pure tone threshold testing must be
performed separately in both ears and participants must not use hearing aids during testing.

PULMONARY EVALUATION
Spirometry
A baseline spirometry must be established in all uniformed personnel who may be required to wear
breathing apparatus. A baseline is useful in individuals who have a history of respiratory health
problems to use for later comparison. Baselines can also be used in individuals without respiratory
disease who later develop respiratory impairment again for comparison purposes. Results can vary
depending on patient’s effort, maximum effort is required, and proficiency of the test administrator,
please note the technician performing this test must be certified in the procedure. The member’s
age, height, gender, and race/ethnicity is used by the technician to optimally calculate and interpret
spirometry results. Significant deterioration, greater than 15 percent from the previous year’s test
indicates further evaluations.
• Spirogram
Only a spirogram that is technically acceptable and demonstrates the best effort by an individual
should be used to calculate Forced Vital Capacity (FVC) or Forced Expiratory Volume (FEV1).
Forced Vital Capacity (FVC)— if the FVC is lower than 80 percent of predicted, this may indicate
obstructive lung disease, restrictive lung disease, or mixed obstructive and restrictive pulmonary
disease.
Forced Expiratory Volume (FEV1)— if the FEV1 is lower than 80 percent of predicted, this may
indicate obstructive, restrictive, or a mixed pattern of obstructive and restrictive pulmonary
disease.
FEV1/FVC Ratio —can suggest the presence of the following pulmonary diseases: obstructive lung
disease if the FEV1/FVC ratio is less than 75 percent of predicted; mixed pattern disease if the
FEV1/FVC ratio is between 75 — 85 percent of predicted and both FEV1 and FVC are reduced; or
restrictive lung disease if FEV1/FVC ratio is greater than 85 percent of predicted and both FEV1
and FVC are reduced. Annual spirometry is the only cost effective screening test. The following
respiratory tests are used when indicated to further evaluate suspected abnormal conditions and
are performed in specialized laboratories.
• Peak Expiratory Flow Rate
A low PEFR may indicate obstructive or restrictive lung disease entities such as asthma or chronic
obstructive pulmonary disease (COPD), but is most useful as a simple measurement to monitor
asthmatic response to therapy. PEFR can be used at home or work to objectively document a
patient’s symptomatic complaints.
• Pre/Post Bronchodilator
Obstructive disease and mixed obstruction/restriction usually, but not always, responds to a
bronchodilator. Restrictive diseases typically do not respond to a bronchodilator. Repeat
spirometry after bronchodilator treatment may provide useful information, but is not required for
data collection purposes.
• DLCO
A measurement of diffusing capacity of carbon monoxide. Low DLCO, less than 70 percent, is seen
in interstitial restrictive lung diseases (e.g., asbestosis and sarcoidosis), chronic CO intoxication, and
obstructive lung disease, less than 60 percent emphysema. DLCO is not reduced in bronchitis or
asthma.
• Lung Volumes
Are low in restrictive diseases, interstitial or chest wall, and are high in obstructive diseases
especially with emphysema.

Initial Baseline Chest X-Ray
A baseline chest X-ray is required and useful for an individual with a history of respiratory
problems or symptoms. It is also useful in healthy individuals for later comparison in the event that
disease develops.
Repeat Chest X-Ray
Unless medically indicated, all uniformed personnel are recommended to have a repeat chest X-ray
every five years.
The use of chest x-rays in surveillance activities in the absence of significant exposures, symptoms,
or medical findings has not been found to reduce respiratory or other health problems. Among
uniformed personnel, chest X-ray abnormality may indicate pneumonia, tuberculosis, lung cancer,
or other occupational lung disease.

AEROBIC/CARDIOVASCULAR EVALUATION
Resting ECG
A resting 12-lead ECG shall be performed annually. It can be useful to diagnose disturbances in
rhythm, presence of conduction defects (e.g., heart blocks), or indications of ischemic heart disease
(e.g., ST segment depression or elevation, T-wave inversions, or Q-waves). Further investigation
may be necessary if any abnormality is seen, or if there is a significant change in the ECG from the
previous year(s).


Aerobic/Cardiopulmonary Testing
A cardiopulmonary test shall be done annually, using either a maximal test under the supervision of
a physician or a submaximal test using WFI protocols. The maximal cardiopulmonary test with ECG
is performed in a medical facility with proper monitoring by a physician and available resuscitation
equipment. Cardiopulmonary/aerobic tests with heart rate monitoring, rather than ECG
monitoring, are conducted on a treadmill or stair mill using the validated protocols contained in
Appendix A. Diagnostic information and a calculated VO2 is obtained from these submaximal tests.

CANCER SCREENING
Appropriate screening examinations: skin, clinical breast examination, Pap smear, testicular,
examination, Digital Rectal Exam (DRE), Fecal Occult Blood Testing (FOBT), colonoscopy, and
bladder cancer examination must be conducted with the annual examination or as indicated below.
When such examinations are carried out on a member of the opposite sex or if the member
requests, a second health care worker chaperone should be in the room for patient support and
medico-legal reasons. Uniformed personnel may, however, choose to have such exams performed
by an outside physician.
Skin Exam
Both melanoma and non-melanoma skin cancers are common and are increasing in incidence. Skin
cancer must be diagnosed in a timely manner to ensure successful treatment and maximize cure
rates. Comprehensive inspection of the skin, especially in sun-exposed areas, is necessary. Inform
the patient that taking a photograph of their own skin (especially their back) can help when
comparing specific nevi (moles) or assessing for new or atypical lesions over time. Any suspicious
lesions shall be referred for dermatological assessment.
Breast Examination
Breast cancer is the most common type of cancer in women and second leading cause of cancer
death in women, after lung cancer. Breast cancer incidence and mortality rates increase with age.
An annual clinical breast examination is required. Self-examination should be encouraged, and
educational information should be made available to interested patients.
Mammogram
Annual mammography screening shall be performed on all women uniformed personnel beginning
at age 40. Women uniformed personnel with a family history of breast cancer or other personal
risks shall be provided with appropriate individualized recommendations for breast cancer
screening, such as genetic screening or breast MRI. Women uniformed personnel may wish to have
an ongoing clinical association with a women’s health provider.
Pap Smear
Annual Pap smear screening is recommended to screen for cervical inflammation or cervical cancer.
The incidence of invasive cervical cancer has been estimated to have decreased 70 percent by
screening. In addition to the Pap test — the main test for cervical cancer — the human
papillomavirus (HPV) test may be used for screening women aged 30 years and older, or if
indicated at any age for those who have unclear Pap test results.
Testicular Examination
Testicular cancer represents 1 percent of all cancers in men. It remains the most common cancer in
Caucasian men 20 to 34 years old. In general, an excellent prognosis exists with early detection and
treatment. Self-examination should be encouraged, and educational materials should be made
available to interested patients.
Prostate Specific Antigen (PSA)
Prostate cancer is the second most common type of cancer in men, after skin cancer. The PSA test is
a screening test for prostate cancer. Male uniformed personnel who are considered to be at an
increased risk for prostate cancer, such as those who have a family history of prostate cancer or are
of African-American heritage, shall have a PSA test annually beginning at 40 years old. All other
male uniformed personnel shall have annual PSAs beginning at 50 years old. Several non-
cancerous conditions might result in elevated PSA levels including benign prostatic hypertrophy
(BPH) and inflammation, or recent prostate gland stimulation resulting from a DRE or ejaculation.
Current consensus also highlights the importance of measuring and comparing PSA results over
time, known as PSA velocity, where an increase over time would indicate higher risk for prostate
cancer, the magnitude of this increase where risk is increased should be in accordance with current
National urological association guidelines.
Digital Rectal Examination (DRE)
Any abnormal DRE for male uniformed personnel, which could be suggestive of cancer, even if PSA
is in a normal range, should be referred to an urologist for a diagnostic workup.
Fecal Occult Blood Testing
Fecal occult blood testing is used to screen for colorectal cancer. Testing is done annually in
conjunction with the DRE. It is done either in the clinician’s office using a stool guaiac card or with
stool specimens collected by the patient at home that are applied to the guaiac cards and later
analyzed by a laboratory. Multiple different stool samples, usually three, from different days can
increase the sensitivity of this colorectal cancer-screening test. Diet restrictions do apply to this
test.
Colonoscopy
Uniformed personnel are exposed to a variety of particulate materials, chemicals and asbestos,
which can increase the risk for colon cancer. Colonoscopies are used to examine the full lining of
the colon and rectum. During the colonoscopy other minor procedures including polyp removal or
excising a small piece of tissue for biopsy may be performed. Colonoscopies shall be conducted on
all uniformed personnel at 40 years old and repeated every five years. A colonoscopy shall also be
performed, regardless of age or schedule, when FOB results are positive or when there is a
consistent change in bowel habits.
Bladder Cancer Test
As the body absorbs cancer-causing chemicals, they are transferred to the blood, filtered out by the
kidneys, and expelled from the body in urine. High concentrations of chemicals in urine can
damage the endothelial lining of the bladder and increase the risk of cancer. Because fire fighters
are regularly exposed to smoke and chemical fumes, they may be at an increased risk for
transitional cell carcinoma (TCC), a cancer of the bladder. Urine is evaluated annually for blood
(hematuria), nuclear matrix protein 22 (NMP22) or for telomerase, an enzyme found in bladder
cancer cells. Positive dipstick for hematuria, telomerase or NMP22 may indicate referral for upper
tract imaging, cystoscopy and urine cytology.

IMMUNIZATIONS
Uniformed personnel must receive, or provide documentation of having received the following
vaccinations: Hepatitis A, Hepatitis B, Tetanus/Diphtheria, Pertussis, influenza, MMR, Polio, and
Human Papillomavirus (HPV). Pneumovax should be considered for individuals with appropriate
risk factors.
Hepatitis A
Formalin inactivated vaccines made from attenuated HAV strains have been shown to be
immunogenic, safe, and highly effective in preventing Hepatitis A. Previous recommendations only
included vaccinations for “high risk” uniformed personnel (e.g., HazMat, USAR, and SCUBA) and
those uniformed personnel who are Hepatitis C positive or have exposure to contaminated water.
However, since all uniformed personnel are potentially exposed to contaminated water via floods
or accumulated water from fire suppression, all uniformed personnel shall be vaccinated.
The vaccine is 99-100 percent effective, so serum titers after vaccination are not recommended.
A new combined Hepatitis A and B vaccination is now available. Immune globulin (IG) contains
anti-HAV with antibody concentration sufficient to be protective. It is to be administered to
uniformed personnel who have not been previously vaccinated before exposure or during the early
incubation period. Immune globulin may not prevent infection, but will weaken the effects and may
render the infection inapparent.
Hepatitis B
Uniformed personnel, by the nature of their occupation, are considered high risk and are therefore
required to have this vaccine. The vaccine is effective in preventing HBV infection. Among the less
than 90 percent who develop adequate antibody levels after the third dose, vaccine effectiveness is
virtually 100 percent. Although antibody levels decrease with time, people with normal immune
systems continue to be protected from infection. Despite the decline of antibody levels with time,
routine booster doses and serologic monitoring are not presently recommended for patients with
normal immune status. Booster doses are not recommended if a previously vaccinated person with
documented immunity is exposed to a known source and if the antibody is now inadequate.
Nevertheless, HBV booster can be administered, depending on the protocol. If vaccination was not
successful, then hepatitis B gamma globulin must be administered after each exposure. If initial
vaccine doses are not sufficient, up to three additional doses can be administered. The following
factors — male, over 40 years old, smoker and obesity — are associated with difficulty in HBV
antibody conversion following vaccination.
Tetanus/Diphtheria
Tetanus and diphtheria occur almost entirely in unimmunized or incompletely immunized persons.
Case fatality rates for tetanus are as high as 30 percent and as high as 5 to 10 percent for
diphtheria. Immunization records of prior vaccinations are required. Uniformed personnel shall be
given tetanus/diphtheria boosters every ten years. For certain high-risk wounds, a booster shall
be given if five years have elapsed since the last vaccine. Epidemiological studies have indicated
that adult immunity to pertussis, whooping cough, is waning. A convenient way to prevent
outbreaks of pertussis is to administer a combination Tetanus/Diphtheria/Pertussis vaccine
(TDAP).
Influenza
The influenza vaccine is 30-40 percent effective in preventing clinical illness and 80 percent
effective in preventing death in older adults. Uniformed personnel are in close contact with the
public and live in close quarters while on duty and therefore the vaccine is required and must be
provided annually, early fall through early winter, for all uniformed personnel.
Measles, Mumps, Rubella (MMR)
Measles remains a significant health problem with recent outbreaks attributed to vaccine failure,
waning immunity, and erroneous documentation of previous vaccination. Mumps has been
increasing in incidence. Use of the rubella vaccine has led to a significant decrease in the incidence
of rubella. Rubella is usually a mild illness. However, in pregnant women particularly in the first
trimester, it can lead to miscarriage, stillbirth, and congenital rubella syndrome (CRS).
Measles
The measles vaccine is required for all uniformed personnel born in or after 1957, if there is no
medical contraindication and no evidence of at least one dose of live vaccine on or after the
individual’s first birthday. In addition, a vaccination is needed if there is no documentation of a
physician-diagnosed disease or if there is no laboratory evidence of immunity. Those born prior to
1957 are presumed to be immune. If in doubt, immunization is appropriate.
Mumps
The mumps vaccine is required for all uniformed personnel who have no documentation of
physician-diagnosed mumps, no adequate immunization with live mumps after their first birthday,
and no evidence of laboratory immunity. Uniformed personnel born before 1957 are presumed to
be immune. Vaccination is needed for uniformed personnel who are unsure of their mumps
vaccination history.
Rubella — the rubella vaccine is required for uniformed personnel unless proof of immunity is
available. Women who receive the vaccine should not become pregnant for three months after the
vaccination is administered.
Polio
The polio vaccine has dramatically reduced the annual number of reported cases of paralytic
poliomyelitis. The vaccine series is usually given in childhood. It shall be given to uniformed
personnel if the vaccination or disease is not documented.
Human Papillomavirus (HPV)
The HPV vaccine shall be provided to all women uniformed personnel up to 26 years old, if
previous vaccination is not documented.
Varicella
Varicella disease, or chickenpox, is a highly contagious childhood disease caused by varicella virus
(VZV). A vaccine is now available. As recommended by the American Committee on Immunization
Practices (ACIP), susceptible persons 13 years old and older who come into contact with those at
high risk for serious complications from VZV disease (e.g., health care workers and those in contact
with immunocompromised individuals) should be vaccinated with two doses at least one month
apart. Uniformed personnel who have not had varicella are considered high risk due to their
occupational exposures. Uniformed personnel should be screened for immunity levels. The
varicella vaccine shall be offered to all non-immune personnel. If immunity to VZV is not
documented, gamma globulin may be indicated after exposure.

INFECTIOUS DISEASE SCREENING
Hepatitis C Virus
Hepatitis C is a major health concern for employees in the fire service. It is very important to
screen for the antibody to the Hepatitis C virus because it can be clinically silent for decades while
causing ongoing damage to the liver. Historically, the vast majority of Hepatitis C infections were
caused by blood transfusions or IV drugs use. The prevalence of Hepatitis C infections in the fire
service has varied considerably where it has been measured. Medical studies have suggested that
new infection (seroconversion) with the HCV in fire service employees is almost always caused by
percutaneous injury events such as with contaminated needle sticks. Baseline antibody tests shall
be done on all uniformed personnel to check for previous infection or to establish the absence of
infection. Be aware that false positive and false negative results may occur. If conversion from
negative to positive occurs, expert consultation for specialized treatment protocols is required.
Tuberculosis (TB)
TB control depends upon screening high-risk populations and providing preventive therapy to
those most likely to develop active disease. Uniformed personnel, by nature of their occupation, are
considered to be at increased risk and an annual PPD is required. A new serum test is available and
may be considered as an alternative to PPD. If annual conversion rates are high in a given work
group, then testing is recommended every six months. A conversion indicates recent exposure to or
infection by, the tubercle bacillus. Personnel will then need appropriate follow-up and contact
investigation as medically indicated. As recommended by the American Thoracic Society and
Centers for Disease Control and Prevention, chest X-ray and isoniazid prophylaxis may be needed.
Human Immune Deficiency Virus (HIV)
HIV testing is not a part of baseline or annual physicals. However, the test should be offered on a
confidential basis as part of post-exposure protocols and as requested by a physician and patient.
All results from HIV tests are provided directly to the patient and will not be maintained in any local
or international database.



REFERRAL TO HEALTH CARE PRACTITIONERS
The following will warrant referrals to health care practitioners: abnormal findings on the annual
medical exam must be addressed by a medical practitioner follow-up or referral; revaccination or
intervention following exposures must be managed by a medical practitioner follow-up or referral;
managed care or other provider referrals are appropriate for non-work related medical issues.

WRITTEN FEEDBACK
Written feedback to uniformed personnel concerning health risks and health status is required
following the annual examination. Reporting findings and risks and suggesting plans for modifying
risks improve the physician-patient relationship and helps uniformed personnel claim ownership
of their health.
Individualized Health Risk Appraisal
Individualized health risk appraisals must also include questions that attempt to accurately
measure the uniformed personnel’s perception of their health. Health perception can be a useful
indicator of potential problems.

DATA COLLECTION AND REPORTING
Comprehensive confidential aggregated medical and health information will be collected for the
purposes of this Initiative. The complete data protocol is found in Chapter Seven. The following is
an overview of the different categories of data to be compiled: demographics, employment status,
illness and injury experience, tobacco and alcohol use, current health status, cancer screening,
physical activity, physical measurements, lab data, immunizations, and fitness testing.

OCCUPATIONAL EXPOSURE
An integrated exposure database that provides the fire department physician timely information on
uniformed personnel aids in tracking diseases in individuals and risks in the population. The
physician must educate uniformed personnel on the importance of documenting exposures and
follow-up care to ensure that the employee gets necessary medical care. The central departmental
database on uniformed personnel must include the following: chemical exposures, physical
exposures, biological exposures, and all safety and health related incidents.